Behavior

When planning care for a client who has ingested phencyclidine (PCP), the nurse's highest priority should be meeting the

client's safety needs.

A new nurse has transferred to the chemical dependency rehabilitation unit. Which action if performed by the new nurse would warrant the change nurse to intervene? a) helping the client to express feelings b) enforcing unit policies c) confronting the client's inappropriate behaviors. d) calling the Narcotics Anonymous group for the client

D calling the Narcotics Anonymous group for the client Explanation: Calling Narcotics Anonymous to tell them to expect the client is inappropriate and unnecessary because it increases the client's dependency on the nurse. It is the client's responsibility to make arrangements for attending meetings. Enforcing unit policies is an important component in establishing a therapeutic milieu. Confronting inappropriate behaviors such as manipulation and use of defense mechanisms such as projection are part of the nurse's role in drug rehabilitation. Helping the client to express feelings appropriately through the use of assertiveness techniques teaches the client appropriate interpersonal skills. (less)

Inhalants S/S

Effects mimic those of alcohol, with dizziness and imbalance Euphoria, headache, disinhibition, altered level of consciousness to coma Renal, hepatic, and cardiac toxicity Aplastic anemia Fetal growth retardation Respiratory depression, arrest from CNS depression Vasodilation Nosebleeding Circumoral red spots/rash Air embolus

A client who reports consuming 1 qt (1 L) of vodka daily is admitted for alcohol detoxification. The nurse anticipates the need to teach the client about which medication?

Lorazepam Correct Explanation: The best choice for preventing or treating alcohol withdrawal symptoms is lorazepam, a benzodiazepine. Benzodiazepines are cross-dependent with alcohol and possess antianxiety and anticonvulsant properties. Both heightened anxiety and seizures are associated with alcohol withdrawal.

Hallucinogens or Psychedelic-Type Drugs

Lysergic acid diethylamide (LSD) Phencyclidine HCl (PCP, "angel dust") Mescaline, psilocybin Cannabinoids (marijuana) Ketamine ("special K") Synthetic cannabinoids ("spice," "incense," "K2")

Hallucinogens or Psychedelic-Type Drugs S/S

Nystagmus Mild hypertension Marked confusion bordering on panic Incoherence, hyperactivity Withdrawn Combative behavior; delirium, mania, self-injury (lasts 6-12 hours) Hallucinations, body image distortion Hypertension, hyperthermia, acute kidney injury Flashback—recurrence of LSD-like state without having taken the drug; may occur weeks or months after drug was taken Ketamine—"out-of-body" experience; increased aggressiveness Synthetic cannabinoids—euphoria, increased sensory experience, relaxation

A client comes to day treatment intoxicated, but says he is not. The nurse identifies that the client is exhibiting symptoms of 1denial. 2reaction formation. 3projection. 4transference.

1

Clonidine (Catapres) is prescribed for symptoms of opioid withdrawal. Which of the following nursing assessments is essential before giving a dose of this medication? 1Assessing the client's blood pressure 2Determining when the client last used an opiate 3Monitoring the client for tremors 4Completing a thorough physical assessment

1

Which type of child abuse can be most difficult to treat effectively? 1 Emotional 2 Neglect 3 Physical 4 Sexual

1

Examples of child maltreatment include 1 calling the child stupid for climbing on a fence and getting injured. 2 giving the child a time-out for misbehaving by hitting a sibling. 3 failing to buy a desired toy for Christmas. 4 spanking an infant who won't stop crying. 5 watching pornographic movies in a child's presence. withholding meals as punishment for disobedience.

1, 4, 5, 6,

The client tells the nurse that she takes a drink every morning to calm her nerves and stop her tremors. The nurse realizes the client is at risk for 1 an anxiety disorder. 2 a neurologic disorder. 3 physical dependence. 4 psychologic addiction.

3

The nurse has provided an in-service program on impaired professionals. She knows that teaching has been effective when staff identify which of the following as the greatest risk for substance abuse among professionals? 1Most nurses are codependent in their personal and professional relationships. 2Most nurses come from dysfunctional families and are at risk for developing addiction. 3Most nurses are exposed to various substances and believe they are not at risk to develop the disease. 4Most nurses have preconceived ideas about what kind of people become addicted.

3

The 12 steps of AA teach that 1acceptance of being an alcoholic will prevent urges to drink. 2a Higher Power will protect individuals if they feel like drinking. 3once a person has learned to be sober, he or she can graduate and leave AA. 4once a person is sober, he or she remains at risk to drink.

4

A nurse is working with a client who abuses alcohol. Which fact should the nurse communicate to the client?

Abstinence is the basis for successful treatment.

Opioids S/S

Acute intoxication (overdose) Pinpoint pupils (may be dilated with severe hypoxia); decreased blood pressure Marked respiratory depression/arrest Pulmonary edema Stupor → coma Seizures Fresh needle marks along course of any superficial vein; skin abscesses (from "popping")

Inhalants

Amyl nitrate Freon Propane Trichloroethylene Gasoline Perchloroethylene Toluene (metallic paint spray) Helium Canned air Hand sanitizer Routes may include: • Sniffing/snorting—direct inhalation of fumes • "Bagging"—sniff from a bag • "Huffing"—sniff from a rag/cloth • "Dusting"—direct spray into the nostrils

A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see: a) slow pulse. b) tension and irritability. c) hypotension. d) constipation.

b Amphetamines are a nervous system stimulant that are subject to abuse because of their ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea, not constipation, is a common adverse effect.

A client admitted for alcohol detoxification is taking disulfiram. The nurse should instruct the client to avoid ingestion of which foods and/or liquids? Select all that apply. a) cough syrup b) beer c) aged cheese d) communal wine at church e) chocolates

b, a, d beer • cough syrup • communal wine at church Correct Explanation: The client who is taking disulfiram is advised to avoid all forms of alcohol including beer, communal wine at church, and cough syrup; these can trigger a serious physical reaction. Aged cheeses and chocolate are to be avoided by the client taking monoamine oxidase inhibitors

After a dose-response test, the client with an overdose of barbiturates receives pentobarbital sodium at a nonintoxicating maintenance level for 2 days and at decreasing dosages thereafter. This regimen is effective in the client does not develop:

seizures. Explanation: Generalized seizures may occur on the second or third day of withdrawal from barbiturates. Without treatment, the seizures may be fatal.

Opioids

Heroin Opium or paregoric Morphine, codeine, semisynthetic derivatives: oxycodone (OxyContin), methadone, meperidine (Demerol), tramadol (Ultram), fentanyl (Sublimaze)

A female client comes to an urgent care clinic and says, "I've just been raped." What should the nurse do? 1 Allow the client to express whatever she wants. 2 Ask the client if staff can call a friend or family member for her. 3 Offer the client coffee, tea, or whatever she likes to drink. 4 Get the examination completed quickly to decrease trauma to the client. 5 Provide the client privacy—let her go to a room to make phone calls. 6 Stay with the client until someone else arrives to be with her.

1, 2, 6

Management for Phencyclidine Abusers

1. Place patient in a calm, supportive environment to minimize stimuli; protect from self-injury. 2. Avoid talking down. 3. Do not leave patient unobserved. Treat symptoms as they occur. a. Drug effects are unpredictable and prolonged. b. Symptoms are likely to exacerbate; patient becomes out of control. 4. Refer all patients in this category for psychiatric and drug evaluation/rehabilitation.

Which of the following would the nurse recognize as signs of alcohol withdrawal? 1 Blackouts 2 Diaphoresis 3 Elevated blood pressure 4 Lethargy 5 Nausea 6 Tremulousness

2, 3, 5, 6

The nurse would recognize which of the following drugs as central nervous system depressants? 1 Cannabis 2 Diazepam (Valium) 3 Heroin 4 Merperidine (Demerol) 5 Phenobarbital 6 Whiskey

2, 5, 6

Which of the following is true about domestic violence between same-sex partners? 1 Such violence is less common than that between heterosexual partners. 2 The frequency and intensity of violence are greater than between heterosexual partners. 3 Rates of violence are about the same as between heterosexual partners. 4 None of the above.

3

Barbiturates

Pentobarbital (Nembutal), secobarbital (Seconal), amobarbital (Amytal), gamma-hydroxybutyrate (GHB, "liquid Ecstasy")

A client recently admitted to the hospital with sharp, substernal chest pain suddenly reports palpitations. The client ultimately admits to using cocaine 1 hour before admission. The nurse should immediately assess the client's: a) pulse rate and character. b) anxiety level. c) level of consciousness. d) neurobehavioral functioning.

a pulse rate and character. Correct Explanation: Cocaine blocks reuptake of norepinephrine, epinephrine, and dopamine, causing an excess of these neurotransmitters at postsynaptic receptor sites. Consequently, the drug is likely to cause tachyarrhythmias. Although neurobehavioral deficits are common in neonates born to cocaine users, these deficits are rare in adults. As craving for the drug increases, a person who's addicted to cocaine typically experiences euphoria followed by depression, not anxiety.

A husband and wife seek emergency crisis intervention because he slapped her repeatedly the night before. The husband indicates that his childhood was marred by an abusive relationship with his father. To assess for the likelihood of further violence and abuse, the nurse should determine that the husband: a) feels secure in his relationship with his wife. b) has learned violence as an acceptable behavior. c) trusts his wife and supports her independence. d) has moderate impulse control.

b Family violence is usually a learned behavior. This couple is at risk for further violence. Poor, not moderate, impulse control indicates a risk for more violence. Violent people generally are jealous and possessive and feel insecure in their relationships

Which of the following assessment findings might indicate elder self-neglect? 1 Hesitancy to talk openly with nurse 2 Inability to manage personal finances 3 Missing valuables that are not misplaced 4 Unusual explanations for injuries

2

Amphetamine S/S

Nausea, vomiting, anorexia, palpitations, tachycardia, increased blood pressure, tachypnea, anxiety, nervousness, diaphoresis, mydriasis Repetitive or stereotyped behavior Irritability, insomnia, agitation Visual misperceptions, auditory hallucinations Fearfulness, anxiety, depression, hostility, paranoia Hyperactivity, rapid speech, euphoria, hyperalertness Decreased inhibition Seizures, coma, hyperthermia, cardiovascular collapse, rhabdomyolysis MDMA is both a hallucinogenic and stimulant. MDPV and mephedrone effects last >24 hours.

Amphetamine-Type Drugs (pep pills, "uppers," "speed," "crystal meth")

amphetamine (Benzedrine) dextroamphetamine (Dexedrine) methamphetamine (Desoxyn, "speed") 3,4-methylenedioxymethamphetamine (MDMA) ("Ecstasy," "Adam")* 3,4-methylenedioxy-N-ethylamphetamine (MDEA) ("Eve") 3,4-methylenedioxyamphetamine (MDA); methylphenidate (Ritalin) "ice," "rocks," "crystal meth" 3,4-methylenedioxypyrovalerone (MDPV) or 4-methylmethcathinone (mephedrone); "Bath salts" (synthetic stimulant)

A hospitalized client craves a drink after withdrawing from alcohol. Which measure is the best way to help the client resist the urge to drink? a) a routine search of visitors b) support from other alcoholic clients c) one-to-one supervision by the staff d) a locked-door policy

b Group support has proved more successful than individual attention from the staff in influencing positive behavior in alcoholic

A client admits to using cocaine and says, "When I stop using, I feel bad." Which effect is the client most likely to describe as occurring after he stops using cocaine?

depression

A client, who was hospitalized after a fall sustained while intoxicated, experienced alcohol withdrawal delirium during the hospitalization. A few days after the client's sensorium clears, the client tells the nurse that drinking helps to cope with anxiety related to a recent divorce. Which response by the nurse would help the client view the drinking more objectively?

"Tell me about the last time you were under a lot of stress and drinking to cope."

Which of the following behaviors would indicate stimulant intoxication? 1Slurred speech, unsteady gait, impaired concentration 2Hyperactivity, talkativeness, euphoria 3Relaxed inhibitions, increased appetite, distorted perceptions 4Depersonalization, dilated pupils, visual hallucinations

2

A nurse is evaluating a client for probable amphetamine overdose. Which assessment finding supports this diagnosis? a) Tachycardia b) Constricted pupils c) Hypotension d) Hot, dry skin

a Amphetamines, which are central nervous system stimulants, cause sympathetic stimulation, including hypertension, tachycardia, vasoconstriction, and hyperthermia. Hot, dry skin is seen with anticholinergic agents such as jimsonweed. Pupils will be dilated, not constricted.

For the client with a substance abuse problem, which intervention would be most helpful to aid the client in dealing with feelings and concerns related to alcohol and drugs? a) solitary activities b) recreation c) group sessions d) individual therapy

c

Which nursing action is contraindicated for the client who is experiencing severe symptoms of alcohol withdrawal? a) assessing vital signs b) monitoring intake and output c) using short, concrete statements d) helping the client walk

d Having the client who is experiencing severe symptoms of alcohol withdrawal walk is contraindicated because increased activity and stimulation may confuse the client and promote hallucinations. The client may also sustain an injury if he has a seizure as part of the alcohol withdrawal process. The nurse should monitor intake and output to ensure fluid and electrolyte balance and hydration. The nurse should assess vital signs to assess the physiologic status of the client and the response to medications. The nurse should use short, concrete statements to decrease confusion and ambiguity.

Cocaine S/S

increase heart rate and blood pressure and cause hyperpyrexia, seizures, increased energy, agitation, aggression, and ventricular dysrhythmias. It produces intense euphoria, then anxiety, sadness, insomnia, and sexual indifference; cocaine hallucinations with delusions; psychosis with extreme paranoia and ideas of persecution; and hypervigilance. Chronic psychotic symptoms may persist. Overall psychotic symptoms are short-lived compared to methamphetamines.

Barbiturate S/S

• Respiratory depression • Flushed face • Decreased pulse rate; decreased blood pressure • Increasing nystagmus • Depressed deep tendon reflexes • Decreasing mental alertness • Difficulty in speaking • Poor motor coordination • Coma, death GHB: • Sexual disinhibition • Amnesia, myoclonus, agitation • Overdoses when mixed with alcohol

Women in battering relationships often remain in those relationships as a result of faulty or incorrect beliefs. Which of the following beliefs is valid? 1 If she tried to leave, she would be at increased risk for violence. 2 If she would do a better job of meeting his needs, the violence would stop. 3 No one else would put up with her dependent clinging behavior. 4 She often does things that provoke the violent episodes.

1

Cocaine Therapeutic management

1. Maintain airway and provide respiratory support. 2. Control seizures. 3. Monitor cardiovascular effects; have antiarrhythmic drugs and defibrillator available. 4. Treat for hyperthermia. 5. If cocaine was ingested, evacuate stomach contents and use activated charcoal to treat. Whole bowel irrigation may be necessary to treat body packers ("mules"). 6. Refer for psychiatric evaluation and treatment in an inpatient unit that eliminates access to the drug. Include drug rehabilitation counseling.

Which of the following is the best action for the nurse to take when assessing a child who might be abused? 1 Confront the parents with the facts and ask them what happened. 2 Consult with a professional member of the health team about making a report. 3 Ask the child which of his parents caused this injury. 4 Say or do nothing; the nurse has only suspicions, not evidence.

2

Which of the following statements would indicate that teaching about naltrexone (ReVia) has been effective? 1"I'll get sick if I use heroin while taking this medication." 2"This medication will block the effects of any opioid substance I take." 3"If I use opioids while taking naltrexone, I'll become extremely ill." 4"Using naltrexone may make me dizzy."

2

On admission a client reports taking disulfiram as part of their home medications. Which of the following would the nurse need to be aware of when coordinating the client's other medications? a) Avoid all products containing alcohol. b) Increase the client's fall risk if taken with antidepressants. c) Collaborate with the doctor for vitamin B therapy. d) Assess the patient for liver injury.

a To avoid severe adverse effects, the client taking disulfiram must strictly avoid alcohol and all products that contain alcohol. Vitamin B therapy isn't necessary during disulfiram therapy. Therapeutic blood levels of disulfiram can't be measured. Disulfiram does not increase the sedative effects of antidepressants.

Which measure should the nurse include in the plan of care for a client with alcohol withdrawal delirium?

remaining with the client when she is confused or disoriented

Inhalant Therapeutic Management

1. Provide airway support, ventilation, and oxygen. 2. Treat cardiac dysrhythmias and hypotension. 3. Provide advanced cardiac life support as needed. 4. Monitor for profound hypotension when amyl nitrate is combined with MDMA and sildenafil.

Barbiturate Therapeutic Management

1. Maintain airway and provide respiratory support. 2. Endotracheal intubation or tracheostomy is considered if there is any doubt about the adequacy of airway exchange. a. Check airway frequently. b. Perform suctioning as necessary. 3. Support cardiovascular and respiratory functions; most deaths result from respiratory depression or shock. 4. Start infusion through large-gauge needle or IV catheter to support blood pressure; coma and dehydration result in hypotension and respond to infusion of IV fluids with elevation of blood pressure. 5. Evacuate stomach contents or lavage if within 1 hour of ingestion to prevent absorption; repeated doses of activated charcoal may be administered. 6. Assist with hemodialysis for severely overdosed patient. 7. Maintain neurologic and vital sign flow sheet. 8. Patient awakening from overdose may demonstrate combative behavior. 9. Refer for psychiatric and drug rehabilitation consultation to evaluate suicide potential and drug abuse.

Hallucinogens or Psychedelic-Type Drugs treatment

1. Evaluate and maintain patient's circulation, airway, and breathing. 2. Determine by urine or serum drug screen whether the patient has ingested hallucinogenic drug or has a toxic psychosis. 3. Try to communicate with and reassure the patient. a. "Talking down" involves understanding the process through which the patient is proceeding and helping him overcome his fears while establishing contact with reality. b. Remind the patient that fear is common with this problem. c. Reassure the patient that he is not losing his mind but is experiencing the effect of drugs and that this will wear off. d. Instruct the patient to keep the eyes open; this reduces the intensity of reaction. e. Reduce sensory stimuli by minimizing noise, lights, movement, tactile stimulation. 4. Sedate the patient as prescribed if hyperactivity cannot be controlled; diazepam or a barbiturate may be prescribed. 5. Search for evidence of trauma; hallucinogen users have a tendency to "act out" their hallucinations. 6. Manage seizures with benzodiazepines (e.g., diazepam) as necessary. 7. Observe patient closely; patient's behavior may become hazardous. Have safety officers stationed near the patient's room. 8. Monitor for hypertensive crisis if patient has prolonged psychosis due to drug ingestion. 9. Place patient in a protected environment under proper medical supervision to prevent self-inflicted bodily harm.

Amphetamine Treatment

1. Provide airway support, ventilation, cardiac monitoring; insert IV line. 2. Use GI evacuation in cases of oral overdose; activated charcoal, gastric lavage if within 1 hour of ingestion. 3. Keep in calm, cool, quiet environment; elevated temperature potentiates amphetamine toxicity. Maintain normothermia, cooling the patient as necessary. 4. Small doses of diazepam (Valium) (IV) or haloperidol (Haldol) as prescribed for CNS and muscular hyperactivity 5. Administer appropriate pharmacologic therapy as prescribed for severe hypertension and ventricular dysrhythmias. 6. Treat seizures with benzodiazepines (e.g., diazepam) as prescribed. 7. Treat sympathetic stimulation with beta-blocker agents as prescribed. 8. Try to communicate with patient if delusions or hallucinations are present. 9. Place in a protective environment (preferably psychiatric security room with video monitoring) to observe for suicide attempt. 10. Refer for psychiatric and drug rehabilitation evaluation.

A client is prescribed chlordiazepoxide as needed to control the symptoms of alcohol withdrawal. Which symptoms may indicate the need for an additional dose of this medication? Select all that apply. a) Elevated blood pressure and temperature b) Mood swings c) Piloerection d) Tremors e) Tachycardia f) Increasing anxiety

• Tachycardia • Elevated blood pressure and temperature • Tremors • Increasing anxiety Explanation: Benzodiazepines such as chlordiazepoxide are usually administered based on elevations in heart rate, blood pressure, and temperature as well as on the presence of tremors and increasing anxiety. Mood swings are expected during the withdrawal period and aren't an indication for further medication administration. Piloerection isn't a symptom of alcohol withdrawal.

Opioids Therapeutic Management

1. Support respiratory and cardiovascular functions. 2. Establish an IV line; obtain blood for chemical and toxicologic analysis. Patient may be given bolus of glucose to eliminate possibility of hypoglycemia. 3. Administer narcotic antagonist (naloxone hydrochloride IV, IM [Narcan]) as prescribed to reverse severe respiratory depression and coma. 4. Continue to monitor level of responsiveness and respirations, pulse, and blood pressure. Duration of action of naloxone hydrochloride is shorter than that of heroin; repeated dosages may be necessary. 5. Send urine for analysis; opioids can be detected in urine. 6. Obtain an ECG. 7. Do not leave patient unattended; he or she may lapse back into coma rapidly. Clinical status may change from minute to minute. Hemodialysis may be indicated for severe drug intoxication. Activated charcoal may be considered if opioids were taken orally and if the patient is alert. 8. Monitor for pulmonary edema, which is frequently seen in patients who abuse/overdose on narcotics. 9. Refer patient for psychiatric and drug rehabilitation evaluation before discharge.

A client is being admitted to the hospital following an inadvertent overdose with oxycodone. He reveals that he has chronic back pain that resulted from an injury on a construction site. He states, "I know I took too much oxycodone at once, but I cannot live with this pain without them. You cannot take them away from me." Which response by the nurse is most appropriate? a) Your pain will be controlled by tapering doses of oxyocodone with other pain management strategies and medicines. b) "You are going to be switched from the oxyocodone to methadone for long-term pain management. c) The oxyocodone will be stopped tomorrow, but you will have lorazepam to help you with the withdrawal symptoms. d) "Once you are tapered off the oxyocodone, you will find that non-addictive pain medicines will be enough to control your pain."

a Tapering doses of oxycodone, pain management strategies, and other pain control medicines are found to be the most helpful with opiate addictions resulting from chronic pain

A client begins to experience alcoholic hallucinosis. After administering medication, what is the best nursing intervention? a) Offering the client oral liquids every 30 minutes b) Providing a quiet environment c) Checking the client's blood pressure every 15 minutes d) Keeping the client restrained in bed

b Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment to reduce stimulation and administering ordered central nervous system depressants in dosages that control symptoms without causing oversedation. Although bed rest is indicated, restraints are unnecessary unless the client poses a danger to himself or others. Also, restraints may increase agitation and make the client feel trapped and helpless when hallucinating. Offering oral liquids every 30 minutes and measuring blood pressure every 15 minutes would interrupt the client's rest. To avoid overstimulating the client, the nurse should check the client's blood pressure and offer him liquids every 2 hours.

A nurse is caring for a client who is experiencing alcohol withdrawal. Which assessment finding indicates the need for an as-needed dose of chlordiazepoxide? a) Blood pressure of 100/70 mm Hg b) Heart rate of 50 to 60 beats/minute c) Heart rate of 120 to 140 beats/minute d) Blood pressure of 140/80 mm Hg

c Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign of alcohol withdrawal. This finding indicates the need for a central nervous system depressant, which may prevent progression of alcohol withdrawal. Blood pressure may be labile throughout withdrawal, fluctuating at different stages. Hypertension typically occurs in early withdrawal. Hypotension, although rare during the early withdrawal stages, may occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don't receive treatment. The nurse should carefully monitor the client's vital signs throughout the entire alcohol withdrawal process

The client sees no connection between her liver disorder and her alcohol intake. She believes that she drinks very little and that her family is making something out of nothing. The nurse interprets these behaviors as indicative of the client's use of which defense mechanisms? a) displacement b) reaction formation c) denial d) rationalization

c The client is using denial, an unconscious defense mechanism, when she refuses to acknowledge that she has a problem with alcohol. This is further evidenced by the client's inability to connect the liver disorder with alcohol ingestion. Displacement involves transfer of a feeling to someone else or to an object. Rationalization involves an attempt to make or prove that one's feeling or behavior is justifiable. Reaction formation is a conscious behavior that is the exact opposite of an unconscious feeling.

When interviewing the parents of an injured child, which sign is the strongest indicator that child abuse may be a problem? a) The family is poor and the mother and father aren't married. b) The parents are argumentative and demanding with personnel. c) The injury isn't consistent with the child's history or age. d) The parents offer consistent explanations for the injury.

c The injury isn't consistent with the child's history or age. Correct Explanation: When the child's injuries are inconsistent with the history given or if the injuries couldn't have occurred naturally or accidentally because of the child's age and developmental stage, the emergency department nurse should suspect child abuse. Consistent explanations for the injury typically don't indicate child abuse. Child abuse occurs in all socioeconomic groups. Parents may argue and be demanding because of the stress of their child's injury

A client with a history of heroin addiction is admitted to the hospital intensive care unit with a diagnosis of opioid drug overdose. While talking with a nurse, the client's father states that he's going to have his son declared legally incompetent. Which response by the nurse is most therapeutic? a) "Your son is ill and can't make decisions about himself and his safety right now, but this situation is temporary." b) "I'll help you contact the hospital legal representative for help with the paperwork." c) "You don't have the right to declare your son incompetent. He has rights, too." d) "If you become your son's guardian, you'll be responsible for his finances and for paying for his treatment."

a The client is temporarily unable to make decisions about his health care and safety. After receiving emergency care and treatment, he'll probably be able to safely manage his daily affairs. The nurse's reference to the client's constitutional rights isn't a therapeutic response. It's antagonistic to the parent's concern and could be a barrier to further nurse-parent interactions. The nurse shouldn't offer to help the client's parent contact the hospital's legal representative; a hospital's legal resources wouldn't be used to help a parent petition a court to declare a client incompetent. A guardian is responsible for making decisions about an individual's welfare and protecting his civil rights. A guardian doesn't assume financial responsibility.

When monitoring a client recently admitted for treatment of cocaine addiction, a nurse notes sudden increases in the arterial blood pressure and heart rate. Which medication should the nurse prepare to administer? a) Nitroglycerin b) Nifedipine c) Norepinephrine d) Lidocaine

b This client requires a vasodilator such as nifedipine to treat hypertension. Lidocaine, an antiarrhythmic, isn't indicated because the client doesn't have an arrhythmia. Although nitroglycerin may be used to treat coronary vasospasm, it isn't the drug of choice in hypertension. Norepinephrine is used to treat hypotension, not hypertension.

A client is admitted to the psychiatric hospital for evaluation after numerous incidents of threatening others, angry outbursts, and two episodes of hitting a coworker at the grocery store where he works. The client is very anxious and tells the nurse who admits him, "I did not mean to hit him. He made me so mad that I just could not help it. I hope I do not hit anyone here." To ensure a safe environment, the nurse should first: a) put him in a private room and limiting his time out of the room to when staff can be with him. b) let other clients know that he has a history of hitting others so that they will not provoke him. c) obtain a prescription for a medication to be administered to decrease his anxiety and threatening behavior. d) tell him that hitting others is unacceptable behavior and asking him to tell a staff member when he begins feeling angry.

d The nurse must clearly address behavioral expectations, such as telling the client that hitting is unacceptable, and also provide alternatives for the client, such as letting staff members know when he begins to feel angry. Making others responsible for the client's behavior or isolating the client in his room is inappropriate because it does not include the client in managing his behavior. Although medication may be helpful, this action does not give the client responsibility for his behavior and is not warranted at this time.

A client, brought to the emergency department by the police, is found wandering the streets of town and appears to be disoriented. When approached by the nurse, the client begins to laugh inappropriately and states feeling dizzy. Which client behaviors suggest the client is symptomatic for huffing aerosols? Select all that apply. a) An elevated temperature b) A slurred speech during conversation c) Impaired memory of where he/she had been d) Multiple bruises on the skin e) An unsteady gait f) Hallucinations of spiders crawling on the bed

• Impaired memory of where he/she had been • A slurred speech during conversation • Hallucinations of spiders crawling on the bed • An unsteady gait Correct Explanation: Huffing inhalants includes common household products such as hair spray, paints, and lighter fluids. Signs of abuse are similar to being under the influence of alcohol. These symptoms include: slurred speech, an unsteady gait, euphoria, dizziness, confusion, hallucinations, and delusions. An elevated temperature is common in cocaine use and bruising is common with intravenous drug users